Employment Type : Full-Time
POSITION: Medical Case Manager, Utilization Review COMPANY: TRISTAR Managed Care DEPARTMENT: Case Management 200200 REPORTS TO: Supervisor, TRISTAR Managed Care STATUS: Exempt Effective Date: 1/26/2021 Position Summary: Responsible for performing Worker’s Compensation utilization review which includes prospective, concurrent, expedited and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence based criteria. Through the discharge planning process, identify patients who have ongoing case management needs and refer these members to the Case Management team for outreach and follow up. Essential Duties and Responsibilities: Additional Functions and Responsibilities Education: Experience: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. SPECIAL EQUIPMENT OR CLOTHING: Professional attire adhering to the Company Dress Code MENTAL AND PHYSICAL REQUIREMENTS Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts. Simple additional and subtraction; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. X Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination. Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application. Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing. Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction. Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants. X Ability to compose original correspondence, follow technical manuals, and have increased contact with people. Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data. Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. X Light work: (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work). Medium work: Heavy work: Very heavy work: Far vision: clarity of vision at 20 feet or more X Near vision: clarity of vision at 20 inches or less X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are Color vision: ability to identify and distinguish colors Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion. Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium. Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles. Kneeling: Bending legs at knee to come to a rest on knee or knees. Crouching: Bending the body downward and forward by bending legs and spine. Crawling: Moving about on hands and knees or hands and feet. Reaching: Extending hand(s) and arm(s) in any direction. Standing: Particularly for sustained periods of time. Walking: Moving about on foot to accomplish tasks, particularly for long distances. Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward. Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion. Foot Motion: Using feet to push pedals. Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles. X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling. X Grasping: Applying pressure to an object with the fingers and palm. Frequently Occasionally FREQUENCY X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts. Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips. X Repetitive Substantial movements (motions) of the wrists, hands, Motion: and/or fingers. Regularly Frequently
MENTAL EFFORT
Mathematical development:
Language development:
PHYSICAL EFFORT
FREQUENCY
Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):
X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
Regularly